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Claremore and Rogers County Disaster Assistance Application

Want to be part of Claremore's Recovery efforts? CRCDA is coordinating with the volunteer crews all over town and we could use your help. Volunteer Application here.

This application is intended to gather information about your immediate priorities and needs for disaster relief. Please note that the information you provide will be reviewed by our personnel to assess the level of need. Submission of this application does not guarantee aid or assistance. Each application will be evaluated on a case-by-case basis.

Contact Information

First Name (Required):

Last Name (Required):

Street Address (Required):

Apartment or Lot:

City (Required):

State (Required):

Zip (Required):

Phone (Required):

Email Address:

What is the best way to contact you? (Required)

What is the best time of day to contact you (Required)?

Immediate Priorities or Needs (Required)

What are your top three immediate priorities or needs for disaster help?
Tree Removal
Electrical
Roofing/Structural
Emergency Housing
Food Assistance
Rent/Mortgage Assistance
Other

Other:

Assistance and Insurance

What assistance have you already requested or applied for?

Do you have insurance to assist with your disaster?
YesNo

Do you have family or friends helping with immediate needs?
YesNo

Are you currently able to live in your residence?
YesNo

If no, will you be able to return and live in your current residence?
YesNo

Number of people living at your residence for each category below. A person may qualify for more than one category listed.

Adults (age 18 or older):

Children (age 18 or younger):

Elderly (age 70 or older):

Disabled Veterans:

Any other individuals with disability:

Individuals with medical needs:

If available, please upload any photos of the damage and/or needs.

Upload Photo 1:

Upload Photo 2:

Upload Photo 3:

Upload Photo 4:

Upload Photo 5:

Upload Photo 6: